Fall is a great time of year for sports! Major League Baseball postseason is heating up. College and Pro football is getting interesting as the dominant teams start to distance themselves from their competitors. High School and college sports are in full swing as a regular part of the fabric of community life.

And for local leagues, colleges and the pros, hockey season is underway! That means excitement on the ice as well as potential for injuries. Given the pace, frequent collisions and contact, and hard surface on which the game is played, head injuries are not uncommon. Shoulder and knee injuries are fairly common as well. The hip experiences unique stresses in hockey, so these injuries warrant consideration and are the topic of this week’s MUSC Health Sports Medicine blog.

When do injuries, especially to the hip, happen in hockey?

A study of collegiate male hockey players showed injury rates are 8 times higher in games compared with practice during the season and usually involve the lower extremity. Knee injuries occurred most frequently during games (14%) while hip and pelvic muscle (groin) strains were most common in practice (13% of injuries). (1) A similar study of female hockey players showed game injury rates 5x that of practice but with hip/pelvic injury rates (12%) in practice second only to concussions (13%). (2) Clearly, hip and groin injuries are important to consider and to avoid in hockey players.

What are the usual hip and groin injuries in hockey and what can be done about them?

Evidence exists to suggest that a muscle imbalance of hip abductors (this group moves the hip/leg outward) compared to adductors (they move the leg inward) can be predictive of groin injury. (3) Groin injuries (adductors) are most common. This finding would support the need for strengthening and conditioning both muscle groups to maintain balance in both offseason and during the season. Another study of youth hockey players suggested an ‘at risk’ position for the hip to experience a condition called femoroacetabular impingement. This condition happens when the femur contacts the socket (acetabulum) abnormally at extremes of motion. The study showed that the sprint start with flexion and internal rotation of the hip pushing to abduction and external rotation initially places the hip in a position of impingement and risks development of overuse injury patterns. Goalies also find themselves in similar positions of extreme hip rotation.

The diagnosis of femoroacetabular impingement has become more prominent in recent years among athletes with hip pain. Hockey players tend to be at particular risk given the extreme positions their hip joints endure. Indeed, it has been shown that elite level youth players have a higher incidence of cam deformity on their femoral heads and also associated hip pain. (5) In this condition, the edge of the ball (or head) of the hip develops a bump of extra bone over time. This extra bone can contact the edge of the hip socket more easily during hip rotation and can actually enlarge over repeated contact with the socket. This contact can ultimately damage the labrum, which is a gasket of sorts on the edge of the hip joint, as well as the cartilage within the joint as well. Youth basketball and soccer players seem to have similar risks for femoroacetabular impingement. (6) In most cases of new onset hip pain, a conservative approach of rest and rehabilitation is enough to settle down the underlying condition. Chronic and persistent pain deserves a more thorough evaluation by a specialist.

Other possible causes of hip pain

Two other conditions should also be noted when a hockey athlete complains of hip pain. If the mechanism of injury is a fall to the ice or perhaps a hard check into the boards, it is possible for a fracture of the hip to occur. While rare, an athlete who cannot bear weight immediately after a hip injury should have a radiograph obtained to rule out fracture. Another condition called ‘sports hernia’ can occur in hockey and other sports that involve regular twisting, pivoting, and hip rotation. In this case, the inguinal wall is weakened and a herniation of abdominal tissue can occur. Deep groin pain is usually present with activity, resolves with rest and does not typically respond to the rehabilitative techniques used for other hip injuries. Surgery is often necessary for these affected athletes to be able to return to play.

For the competitive hockey athlete, maintaining hip strength and flexibility is important. Hip pain that does not respond to rest or is progressively worsening should be evaluated by a sports medicine specialist like those of the MUSC Health Sports Medicine Team.